Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Hospice Quality Reporting Program (CMS-10390)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form Form and Instruction
HIS_UserManualVersion_3.0_February2021.pdf Instruction
HIS_UserManualVersion_3.0_February2021.pdf Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf Form and Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10390	Hospice Item Set - Descriptions	CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Discharge	CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf	Yes	Yes	Fillable Fileable
Instruction			HIS_UserManualVersion_3.0_February2021.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Hospice Item Set (HIS) System	FR Citation: 79 FR 19341

Number of Respondents: 5,640	Number of Respondents for Small Entity: 4,850

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,763,850	2,763,850
Annual IC Time Burden (Hours)	1,323,883	1,323,883
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.